Sunday, June 24, 2012

You Have Cancer! How to Deliver Bad News to Patients.

When I see patients in the office, I try to guess their occupations from their demeanor and mannerisms. Salesmen are the easiest to ID. In general, they are gregarious males with manly handshakes. They laugh loudly and like to tell jokes. Teachers are more reserved and often give their narrative in a logical and chronological order, as would be expected. Another clue that the patient is an educator is that their appointments are usually in late afternoons. I have a solid record picking out the engineers and scientists. (For physician readers, I estimate that with regard to engineers, my sensitivity and specificity are 60% and 90% respectively.)

Engineers can be tough patients for gastroenterologists to treat. They operate in a computational universe, where numbers add up and problems have concrete solutions. Doctors, particularly gastroenterologists, function in an entirely different milieu. Our world is nebulous. Engineers see mathematical truths, while GI physicians see fog. When they see us with chronic nausea and abdominal pain, they are frustrated when we cannot provide them with a satisfying diagnosis.

I recall an engineer I saw some time ago. He was neatly attired and related his ominous symptoms in an intellectual manner, as if he were giving traffic directions. He was having trouble swallowing his food and was steadily losing weight, a presentation that generates the highest level of physician concern.

I scheduled him for a scope examination of the esophagus, and found the expected cancer. Afterward, he was seated with his wife as they awaited the news of my findings.

These minutes when we physicians know the bad news, and the patient doesn’t, are ponderous. We wish we could hold on to the secret and spare patients from the knowledge that will change their lives so brutally and irrevocably. Subconsciously, we stall. During those minutes, hours or sometimes days, physicians are in a different dimension, a medical ‘twilight zone’. Once we relate the news, however, we are hurled back to earth. Once the patient knows, then we are enveloped by an aura of cold reality.

How should physicians give bad news to our patients? Should we be blunt? Do we front load the heavy news or lead to it after several introductory sentences? Should we use euphemisms like ‘growth’, when cancer is the right word? Should we spin the information with hope and optimism, even if the medical facts contradict this assessment? Do we tend to sugarcoat for our own benefit as well as to soothe the patient? Should serious medical news ever be delivered on the telephone? How do we respond if the patient asks, “am I going to die?”

There is no standard strategy of how to do this right. In addition, patients are distinct human beings and must be approached individually. See First, a blog that emphasizes the importance of communication between physicians and patients, writes that false hope for patients may be the wrong prescription. Medrants, an academic physician and thoughful blogger, speaks for all physicians when he writes, breaking bad news may be the most difficult and important part of our profession.

I have spent 4 years in medical school, 3 years in an internal medicine residency followed by 2 years of fellowship training in gastroenterology. During those 9 years, I don’t recall a single lecture on how to deliver bad news to patients. Yet, I remember memorizing biochemical equations, the names of minute nerves and muscles, the function of microscopic components of cells, hundreds of medications and the natural history of arcane diseases that I have never seen in my career. The astute medical interns and residents I admired were those who could spew off the dozen or so medical explanations for an elevated calcium blood level. I wonder if medical training, at least in my day, had proper priorities for training physicians. Doc Gurley, a physician and folksy and irreverent blogger, recalls a single lecture she heard as a medical student on how to deliver bad news to patients. It impacts her practice to this day, two decades later.

Delivering bad news is a very difficult and unavoidable responsibility of a physician. Do I do it well? I think so, but I’m not really sure. I gave the news to my patient and his wife after I had made arrangements for him to see the necessary consultants in the coming days. I think that patients’ stress in these situations is eased when there is a plan that we physicians put in place. He listened without demonstrating emotion, and thanked me for my time. He then left with his worried wife. The news was still in his analytical left brain, where he stores his facts, figures and formulae. What happens when it crosses the Rubicon over to the other side?

4 comments:

Toni Brayer, MD said...

This is so true. I have no idea if I deliver bad news right or wrong. It is hard. You want to do it in person and never on the phone but when you tell a patient to come in their anxiety is sky high. What if they just ask on the phone...do you say "No, I want to see you in person". That is awkward and not helpful. Like you, I always try to have the plan arranged ahead so there is a next step. It is rather odd that we were never taught anything about delivering tough news. I hope the new doctors in training are getting a different education....

Chrysalis Angel said...

I liked this post, Michael.

As one being on the end of that kind of news, you want to feel that your physician cares about the news he/she is giving you-that they care about you as a person. And yes, you'd like to know that your team is in place.

You want to know that your physician has set up the next steps for you, because from that moment on..you will be on auto pilot trying to digest what the whole thing means to you, physically, emotionally, financially, and spiritually. The last thing you want to worry about is who to contact, where to go and when.

The best way to deliver the news is with true compassion, and honesty. You will have to gauge your patient's state as you go and act accordingly, as you do.

My surgeon wouldn't even say the word "cancer" to me. I had to say it to him first. It was so difficult for him to look at me at 36 and tell me. I felt for him. Sometimes, your patients really will already know. I knew.

It is a difficult thing on both sides. The best you can do is be one human being to another in that moment. Their lives will be forever altered, it deserves the time frame to do it with reverence.

Michael Kirsch, M.D. said...

Chrysalis, appreciate your thoughtful response. You've been there.

Anonymous said...

To me this is an unusual, but necessary blog for MD's to read... As a doctor and recent patient.. I am appalled at how little power a patient has over their future as a patient... There are technical things to question, if a patient dares, but there is a whole realm of uncertainty, that any sentient human being can engage on, in their quest for cure or palliation... Need to know the facts, apply the local culture, family understanding etc...Patients can know stuff that a doctor does not, and is essential for cooperation or rejection...Patient's must also "hear" what the MD or DO has to say, and then the input has to have time to percolate and be returned.. A ruptured appendix has a small time for consideration, a ruptured aorta, collapsed lung, a gunshot wound have even less.... The MD approach to gain trust is what this article is about... Needs lots of discussion at the Medical School Level, to make it work at the point of necessity.. Playing "god" no longer works... Talk to a Jehovag's Witness with a ruptured spleen!

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